[acb-diabetics] Excerpt about weight loss

Tue Oct 16 17:13:38 EDT 2012

The weeks excerpt answers the following questions:

*	How important is timing of meals? 
*	How flexible can meal timing be? 
*	What is the traditional gauge to measure obesity? 
*	What are the forces that can affect the ability to achieve a desired
weight? 
*	How effective is providing a weight-loss goal? 
*	Timing of Eating 

Timing of Meals

Though the timing of food consumption is important, newer pharmacologic
treatment agents have made the need for precision of meal timing less
crucial.

For people whose diabetes is not insulin-treated, the total daily caloric
intake should be modified based upon the person's individual goals. For
those people who tend to skip meals, distribution of calories throughout the
day may need to be addressed. For people treated with insulin, food intake
should coincide with the peak action times of the insulin. Typically,
traditional diabetes meal plans often included several snacks consumed at
insulin peak times. However, the newer insulin analogs and insulin treatment
designs allow more flexibility. The rapid-acting insulins that peak sooner
and mimic the timing of natural insulin, such as lispro, aspart, and
glulisine, are being combined with effectively designed basal insulin
programs using repeated injections of intermediate insulin (NPH), or more
commonly the long-acting insulins glargine or detemir (see Chapter 9). These
basal programs recreate the smoother, peakless, natural basal effects more
precisely and avoid having large quantities of intermediate or long-acting
insulin peaking at once. Therefore, meal timing can now be more flexible, as
it is not as crucial to match a meal with the time that a large insulin dose
may be having significant action.

Obesity

Obesity is epidemic in today's society among people with and without
diabetes. While medical conditions may be the cause of obesity in a small
minority, the basic reason that most are obese is that they consume more
calories than they burn for energy. Obesity is becoming more of a problem in
children, as well, and the result is that the incidence of type 2 diabetes
in this young population has increased markedly in recent years.
Contributing to this epidemic may be factors such as cutbacks in funding for
school physical education, too much television, or the popularity of
computer and video games. The 12 year old of a previous generation spent a
weekend afternoon playing outside with friends, while 12 year olds now are
more likely to spend that afternoon sitting at the computer, online with
friends. To make matters worse, many eat out of habit and nibble while
sitting by the computer, by the television or when doing homework.

Body mass index (BMI), which evaluates weight in relation to height, is the
traditional gauge to measure obesity. It is defined as the body weight in
kilograms divided by the square of the height in meters, or the weight in
lbs multiplied by 703 and divided by the square of the height in inches.

dcms106CG1

As BMI levels increase over 25, so, too, does the health risk (see Table
5-1). According to the National Heart, Blood and Lung Institute (NHBLI),
"overweight" is defined as a BMI of 25 to 29.9 kg/m2, "obesity" is defined
as a BMI >30 kg/m2 and severe obesity as a BMI>40 kg/m2.

Another key measure in weight and body-fat assessment is waist
circumference. It is now known that waist circumference is a stronger
predictor of cardiovascular disease (CVD) outcomes than BMI. Measuring the
waist circumference gives an indication of the extent of abdominal fat, or
central adiposity, which is fat that is more "metabolically active." A high
amount of abdominal fat predisposes a person, not only for heart disease,
but also for type 2 diabetes, high blood pressure and dyslipidemia as well.
American men with a waist circumference of 40 inches or greater, and
American women with a waist circumference of 35 inches or greater are at
increased risk for CVD. In other ethnic groups such as Asians, the risk
starts to increase at much lower waist circumference.

Waist circumference, along with BMI, blood pressure, blood glucose and blood
lipid levels, should be measured in a primary care setting to identify those
patients who are at cardiovascular risk.

Unfortunately, in many cultures obesity is confused with prosperity and good
health. Obesity can also run in families, both through inherited tendency
and also by learned eating habits and ethnic diet preference. Psychological
issues can also contribute. Loneliness, depression, and anxiety can lead
people to seek gratification by eating. Specific considerations for
developing a weight loss program will be discussed later in this chapter.

Weight Loss

To lose weight, people must either take in fewer calories or burn up more
calories, or both. Exercise alone does not usually result in significant
weight loss; it is effective when accompanied by a lower caloric intake and
behavioral modification. With weight loss, insulin works more effectively
and less insulin is needed. Triglyceride levels also decrease, and glucose
tolerance improves, signifying improved diabetes control. The amount of
energy used and the basal metabolic rate decrease with weight loss as a
result of a low-calorie diet alone; this can slow down metabolism and may
cause a "plateau" in weight loss. Adding exercise, especially with a
relatively higher protein intake usually makes the difference by maintaining
lean muscle mass. To summarize this dual pronged approach to weight loss,
Dr. Joslin, in a humorous vein, has been quoted in many past publications
musing that one of the best exercises is pushing oneself away from the table
before one is full!

Other forces can affect the ability to achieve a desired weight:

*	age 
*	ethnic customs and beliefs 
*	family habits 
*	lifestyle factors 
*	psychological issues 

Setting a realistic weight-loss goal is an important part of any weight loss
program. Rapid-weight-loss programs rarely work in the long-run and should
be avoided or only used in extreme situations. In addition, telling a person
who is 50 pounds overweight that his or her goal is to lose those 50 pounds
is of little use, as the person will invariably fail because such a goal is
overwhelming. Once the initial weight loss plateaus, frustration often leads
people to abandon their efforts.

Goals should be short- to medium-term, and realistic. The 1994 nutrition
recommendations developed by the ADA changed the way we send messages to our
patients about setting unrealistic goals for weight loss.

Moderate weight loss can result in a significant improvement in blood
glucose in people with type 2 diabetes who are overweight or obese. It may
not even be necessary to achieve "desirable" body weight -- in many
instances, a 10 to 20 pound weight loss (7 to 10% of body weight) is
sufficient to significantly improve insulin sensitivity and glycemic
control. Therefore, achieving a "reasonable" weight (the weight that a
patient and provider agree can be achieved and maintained) may be a more
realistic goal.

In addition, targets should be designed in steps or increments. For example,
a person who is 50 pounds overweight might be given a goal of losing 10
pounds over a 3-6 month period. This goal is realistic and not so
overwhelming. In addition, someone 50 pounds above ideal body weight may
only need to lose 10 to 20 pounds to have a significant impact on metabolic
parameters.

Providing a weight-loss goal is often ineffective if it is not accompanied
by recommendations for specific behavior changes. Determine caloric intake
levels as previously discussed and then use those levels along with
information obtained from the nutritional assessment to design a specific
medical nutrition therapy plan.

 <http://www.nhlbi.nih.gov/guidelines/obesity/bmi_tbl.pdf> For a complete
Body Mass Index (BMI) Table in a pdf format you can easily download or print
out, see this chart from the National Heart and Lung Institute.

Next Joslin Excerpt: Initiating Medical Nutrition Therapy

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